Provider Demographics
NPI:1417165465
Name:STAY, ROURKE M (MD)
Entity Type:Individual
Prefix:
First Name:ROURKE
Middle Name:M
Last Name:STAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:717 20TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31902-2787
Practice Address - Country:US
Practice Address - Phone:706-653-0292
Practice Address - Fax:706-653-1162
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012403712085R0202X
CAA1084382085R0202X
GA0644322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G707915OtherGROUP NUMBER FOR CDC ON COMER
GAP00882634OtherRR MEDICARE
GA202G707915OtherGROUP NUMBER FOR CDC ON COMER